This proposed study will apply an extensively tested nursing intervention to post-surgical cancer patients who are newly diagnosed with advanced cancer. Symptom distress, unmet treatment goals, complications, emergency visits, and costly readmissions to the hospital are common when patients at high risk for post- operative complications are discharged from the hospital with unmet needs and fragmented care. The study's overall purpose is to implement our evidence based Advanced Practice Nurse (APN) intervention using the RE-AIM model (Reach, Efficacy, Adoption, Implementation, Maintenance) to evaluate clinical outcomes and the sustainability of the intervention in medical oncology. The specific aims are to: 1) Integrate discharge planning into an intervention provided by an oncology APN for high risk adults with advanced cancer after surgery;2) Evaluate the effects of the nursing intervention provided by APNs to patients with advanced cancer after surgery to improve clinical outcomes, reduce complications and health care utilization;and 3) Explore the reach, adoption, implementation, and maintenance of a nursing intervention delivered by APNs to facilitate the transition of patients from surgery to medical oncology in a comprehensive cancer center. A cluster randomization procedure will assign disease specific medical oncology clinics at Yale Comprehensive Cancer Center into 2 groups: a treatment group (who will implement the APN intervention) and an enhanced control group (who will provide the standard usual care plus a copy of the symptom management toolkit with instructions on its use). One hundred and forty patients with advanced cancer recruited from the surgical units at Yale New Haven Hospital will provide outcome data that will be compared at 3 data points (baseline, 1 and 3 months post-surgery). The effects of the discharge coordination and APN intervention will be evaluated using self-report questionnaires and health care utilization outcomes. The adoption, implementation, and maintenance process variables will be evaluated through documentation and interviews. This application provides a unique opportunity to implement our intervention in transitioning patients across settings: in-patient to ambulatory care and improving the quality of their lives throughout the illness trajectory. The results will be used to submit a multi-site clinical trial. PUBLIC HEALTH RELEVANCE: This proposed study will apply an evidence-based nursing intervention to post-surgical patients who are newly diagnosed with advanced cancer. The intervention will facilitate patients'transitions between services (surgery to medical oncology) and settings (inpatient to ambulatory care). The intervention will jump start patients'introduction to palliative care at the beginning of their diagnosis and treatment in order to maximize their journey throughout the illness trajectory.